The team was told that the never event would be analyzed, as well as their allegations of staffing issues in order to determine the cause, as well as strategies to preventing a reoccurrence of the event. A never event is a serious reportable event or error that should never occur. The serious reportable events encompass serious adverse events that occur in hospitals that are in large part preventable, as well as of concern to the public, and health care providers (Lembitz & Clarke, 2009). The Agency for Healthcare Research and Quality or AHRQ (2014) states that the list of never events has expanded to signify adverse events that are unambiguous or clearly identified and measurable, serious that result in death or significant disability, and are usually preventable. The defined list of never events by the National Quality Forum (NQF) has been expanded to include twenty-nine events that are separated into six categories (Agency, 2014). The categories include: surgical, product or device, patient protection, care management, environmental, radiologic, and criminal …show more content…
These approaches are Total Quality Management, Continuous Quality Improvement, Lean, and Lean Six Sigma. One of the principle goals of Total Quality Management or TQM is to improve quality by ensuring conformance to internal requirements (Legacy, 2010). To accomplish this, the article (2010) states that errors in production or service process must be reduced, an increase in customer satisfaction must occur, as well as ensuring staff is trained, and retrained. Continuous Quality Improvement or CQI is an approach to quality assurance that builds on traditional methods by building, and strengthening organization and systems, as well as focusing on process rather than individuals (Legacy, 2010). ASQ states that Lean and Lean Six Sigma applications in healthcare require an understanding of how tools and methodologies translate to the people-intensive processes of patient care (ASQ, n.d.). The article (n.d.) states that lean eliminates non-value added activities and waste, which saves money as well as time. Six sigma increases patient satisfaction and reduces errors by improving processes (ASQ,